1. Project: Ghana Emergency Medicine Collaborative Document Title: Adrenal Insufficiency/Crisis Author(s): Andrew Wong (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1

2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2

3. Objectives Diagnosis and Management of Adrenal Insufficiency/Crisis 3

4. Case 70yo M with history of stroke leaving him with residual left-sided weakness presented to the ED for altered mental status. Family states that this past week, he has been having a cough productive of yellow sputum. He has been having decreased alertness since yesterday. He has been refusing to eat and has been seen sweating. 4

5. Case PMH: CVA PSH: None Meds: None All: NKDA SH/FH: Lives at home with son and daughter- in-law. No alcohol use/illicit drug use, tobacco use 5

6. Case Physical Exam – T 38 BP 72/42 HR 120 RR 10 O2 sat 87% ra – Gen: Thin elderly gentleman laying in bed with mouth opened, unresponsive to voice or pain. GCS 3 – HEENT: MM dry with thick yellow coating on mouth. OP otherwise appears clear with no tonsillar erythema or exudate – Neck: soft and supple with no lymphadenopathy – Chest: Reduced breath sounds in bilateral bases. Rhonchi heard in the right lung base – CV: Tachycardic but regular rhythm, no murmurs, rubs, or gallops – GI: Soft, non tender, no masses palpated – GU: Uncircumcised penis – Extremities: cool to touch, weak pulses felt in the periphery. – Skin: No rashes, or decubitus ulcer. + skin tenting. 6

7. Case Differential: Management 7

8. Case SIRS/Sepsis/Severe Sepsis/Septic shock? CVP? 500 cc Bolus MAP? SvO2?HCT? Vasopressor (NE preferred) Transfuse Inotrope (Dobutamine preferred) > 8-12 < 65 > 65 < 70% < 30% > 30% Consider Mechanical ventilation Steroids if persistently hypotensive Source unknown 8

9. Adrenal Insufficiency Background – Adrenal gland consists of cortex and medulla Cortex: cortisol, aldosterone and androgens Medulla: catecholamines n of cortisol: Gluconeogenesis and lipolysis Inhibiting insulin secretion Anti-inflammatory/immune-modulating effects Promote catecholamine synthesis Augmenting vascular reactivity to promote vasoconstriction 9

10. Adrenal Insufficiency Pathophysiology – Primary failure (aka Addison’s disease) Deficiency of cortisol and aldosterone production 10

11. Adrenal Insufficiency – Secondary failure Due to decreased production of ACTH Deficiency of only cortisol production Aldosterone is regulated by renin-angiotensin system 11

12. Adrenal Insufficiency Symptoms – Chronic failure vague and nonspecific 12

13. Adrenal Insufficiency 13

14. Adrenal Insufficiency Acute symptoms – Ranges from acute gastroenteritis with nausea, vomiting, fever and dehydration to vascular collapse or death – Hypotension or shock out of proportion to severity of illness. – Additional symptoms based on etiology: Abdominal pain for adrenal hemorrhage/infarction Headache suggesting acute pituitary apoplexy 14

15. Adrenal Insufficiency Differential Diagnosis – Chronic Anorexia Carcinoma Chronic fatigue syndrome Polymyalgia rheumatica Myopathy Hypothyroidism Flu syndrome – Acute Various causes of shock 15

16. Adrenal Insufficiency Diagnostic strategies – Chronic – AM cortisol measurement (normally 10 and 20 mcg/dL) » If below 3 mcg/dL is diagnostic of hypoadrenalism » If above 20 mcg/dL excludes diagnosis – ACTH (cosyntropin) stimulation test confirmatory » Obtain baseline cortisol » Then administer 250mcg of ACTH » Repeat levels at 30-60min » Normal levels should exceed 20mcg/dL – AM ACTH level » High level confirms primary » Low level confirms secondary 16

17. Adrenal Insufficiency Diagnosis (cont’d) – Acute crisis Random cortisol – <15 mcg/dL = diagnostic – 15-33 mcg/dL = indeterminant – >33 mcg/dL = excludes ACTH stimulation test – Rise of< 9 mcg/dL diagnostic – Hypoadrenalism of Sepsis and Critical Illness Random cortisol <25 mcg/dL = likely ACTH stimulation test <9 mcg/dL = diagnostic 17

18. Adrenal Insufficiency Management of acute insufficiency – ABCs, 2 large bore IVs place – Look for underlying cause – Infuse 2-3 L of 0.9% NS – Check for hypoglycemia – Give Hydrocortisone 50-100mg q6-8 hrs Taper after 24 hours Dexamethasone (o.1 mg/kg) – Advantage of not interfering with cortisol measurement 18

19. Sources Kairam V. Sepsis in the ED. Presentation given on 17 Mar 2011. Klauer K. Adrenal Crisis in the Emergency Medicine. eMedicine Emergency Medicine. 16 Dec 2009. Marx J. Rosen’s Emergency Medicine, 7 th Ed, 2009. 19